Writing with Scissors is the blog site of Howard Rodenberg, MD MPH, former Kansas State Health Director and columnist for the Journal of Emergency Medical Services (JEMS). He is a father, emergency physician, and slightly-past-fifty curmudgeon with great hair for his age. The "scissors" in question refer to those used by editors to weed out all things opinonated, controversial, or politically inappropriate...translated as "anything funny."

a new day
-
2016 is literally around the corner, leaving me with 18 months to
retirement. Its with a mixture of trepidation, expectation and hope that I
turn the page....

1 year ago

Monday, April 20, 2015

Poisons and Productivity

The pharmacist in the ED
sets a packet of paper in front of me, proclaiming with more than a hint of
irony that this is from the Poison Control Center.She says it like this because as far as he
can tell, the Poison Control Center does very little besides telling people to
go to the ER and sending faxes, and has nothing at all to do with the real work
of patient care.The Poison Control
Center used to be a thing, though...tucked way deep in the bowels of most
children's hospitals, they maintained a mythic quality as the repository of all
toxic expertise which they would deign to share with the poor mortals when
asked on bended knee.However, as more
ER residents rotated through these hospitals, we saw the Poison Control Center
for what it was, a technician in a windowless basement room playing solitaire
waiting for someone…anyone…to call so they could read to them off a microfiche
(yep, I'm that old) whatever the latest case report was from the Lesser
Mongolian Journal of Yak Toxicity.Eventually,
the docs figured that we can read a microfiche, too; and as
time elapsed we could do one better and look up things on the internet. Plus clinical overdose management has
progressed remarkably, and in many ways has retreated from some of our more
aggressive care of days gone by.No more
pumping stomachs, no more ipecac-barfing, no more drinking the charcoal and
pooping out briquets.(Pro tip:They still need lighter fluid, but watch out
for the pockets of methane. They explode.)I actually miss those days; as a true believer
in the occasional benefits of punitive therapy, I thought it sometimes did a
word of good for those people who were using pretend overdoses to manipulate
others to go through a little discomfort themselves, perhaps as a reminder that
actions have consequences.

Aside from a few specific
antidotes, overdose management is essentially protecting airways, stabilizing vital signs,
and managing complications, exactly like it is in any other patient. It's all pretty basic stuff.So now all the Poison Control center has to
do is tell people to go the ER and fax things telling us that Yak spit is
highly toxic to...well, nobody, but that there was a case report of a Westerner
who got bit by a Yak in 1974 and was so afflicted he abandoned his wife and
family and lived in a yurt for three years before resuming his role as the
second-best insurance agent in Chillicothe, Missouri.So we should probably admit the patient for
observation just in case this occurs.

*************************

One of the trends in
emergency medicine is to reimburse physicians based on RVU's.An RVU is a relative value unit, and it was
created to quantify the relative work load, experience, knowledge and time commitment
related to a particular medical procedure or patient encounter. The idea is
that the harder you work, the more patients you see and the more RVU's you
generate.It's a variation of fee for
service that basically means you eat what you kill.And it's a radical departure from traditional
emergency medicine pay which is based on a hourly rate.

While I understand the
desire to drive productivity through incentivizing physicians, I'm not sure
that the RVU system is right for emergency medicine.The RVU system works best when a physician
has control over his patient population and daily workload.In that event, you can choose to work
harder, faster, and drive up more RVU's. The ER doctor, however, cannot control
his patient load.People either show up
at the door or they don't, and you can't control for the complexity of the
patients.There is every chance for a
doctor gets penalized because it's a slow shift or because critical patients or
social catastrophes (and there's a lot of those) decrease your overall
productivity.But I also think the RVU
system can act as perverse incentive.On
one hand, it encourages slipshod medicine, as the goal is to generate more
RVU's by running patients through the system as fast as you can. Things can get
missed, patient education can be compromised, and patient satisfaction falls as
they feel "rushed" through the system.On the other, it drives up costs, as one of
the ways to escalate the RVU's without taking more time with the patient is to
order lots of x-rays, lab studies, and consultations, sometimes by protocol
even before a provider actually sees the patient.

Those proponents of the
RVU system might point out that a strict hourly salary promotes lethargy.Why should someone work hard, or harder, if they're
getting paid the same amount no matter how much effort they expend?The answer to that, I think, is something as
simple as professional pride.Nobody wants
to be known as the slowest doc in the group, and even less as an outlier even
if your pace is off.It irritates your
colleagues who, at the change of shift, walk into a full waiting room and an ER
full of half-done checkouts even on good days.And if the behavior persists, eventually the group finds its’ way
without you.

I should also confess
that there is a "sore loser" component to my complaints.Reimbursement rates for RVU's were determined
the same way all reimbursement rates were calculated; through prolonged
lobbying, begging, and cajoling.When
the system came out, the clear winners were the more procedure-based
specialties.Which is why, with the same
four years of training, an eye doctor can charge a small fortune for spending
twenty minutes removing a cataract, while I get a fraction of the dollars for
spending an hour with a critical patient saving their brain, heart, lungs, and
everything else that makes that eyeball possible.Not that I dwell on it, at least not too much.My comfort is that primary care specialists
(family physicians, pediatricians) have it a lot worse.

(This reminds me of an
entire sequence of jokes about doctors and money, courtesy of Drs. Kevin
Dishman and Frisco Morse:

How do you hide a dollar
from an internist?

Hide it under a wound dressing.

How do you hide a dollar
from a surgeon?

Tape it to the EKG.

How do you hide a dollar
from an orthopedic surgeon?

Tape it to the chart.

How do you hide a
hundred dollar bill from a pediatrician?

It doesn't matter.They've never seen one.

Okay.maybe you had to be there.)

********************

I had just gotten back
from a meeting talking about RVU's when the Poison Control paperwork landed on
my desk.The patient had ingested
something called Krud Kleener, which turned out to be a weak alkali, kind of
like bleach.Nobody dies from
bleach.(I've heard rumors, though, that
everyone who drinks bleach gets whiter and starts to channel Neil Diamond.I am, I said, to that damn chair.)

Now, if I had been an
RVU guy, I would have gotten a bunch of labs.I might have given a dose of charcoal as well.Maybe the stuff could have eaten though the
esophagus or stomach and caused a perforation. I can look for that with an
x-ray, or maybe even a CT scan. I could toss an EKG into the mix as well.The fact that none of this would have been
supportable by the medical literature is besides the point. Given a small
amount of medical knowledge and a smattering of latin terminology, the
enterprising clinician can justify anything.

But I don't do
that.I don't do it because of any
particular drive towards cost-efficiency or the practice of
evidence-based medicine. I don’t because I'm lazy, because I know that nothing
I could do is going to make any clinical difference, so why bother.I also don't do it because I know there's got
to be a good story here, because the patient drank from a bottle (brought to
the ER)most clearly labeled KRUD KLEENER,
and I'm the kind of guy who's willing to kill his productivity to hear the
tale.

It turns out that
unbeknownst to me, locked inside my HVAC-sealed workplace cocoon, it had been a
hot day outside in the real world.The
kind that makes people who are standing outside watching a yard crew cut weeds
want to drink something.Anything, in
fact, that looks like water, even if it says Krud Kleener on the bottle set
aside in the corner of the garden trailer, because she was pretty sure that the
crew had put extra water in there because, as you know, it was a hot day.

At this point, I've
already lost some RVU's by taking the time to hear the story.So why not go ahead and cut my productivity
to the bone with a little non-reimbursable patient education?A little Socratic method, please.

"I think you'll be
just fine.But what have we
learned?"

"Well, it's not
really that guy's fault for me thinking it was water."

A patient pedagogical
moment. "No, let's try that again.What have we learned?"

"That I should have
stopped after the first mouthful tasted bad?"

"True, but what
have we learned today that will keep us out of trouble tomorrow? What should we
do if it says KRUD KLEENER on the label?"

There's a look of
puzzlement, and then enlightenment breaks out on her face like the sun after a
summer afternoon storm.

"I don't drink
it!"

Another successful
patient encounter, another crisis averted.But done way too cheaply. No RVU's for me.Should have ordered a CT scan.